1285875344 NPI number — MR. KENNETH R DUBOIS III DDS

Table of content: MR. KENNETH R DUBOIS III DDS (NPI 1285875344)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285875344 NPI number — MR. KENNETH R DUBOIS III DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DUBOIS
Provider First Name:
KENNETH
Provider Middle Name:
R
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
III
Provider Credential Text:
DDS
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1285875344
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/08/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1204 N BROAD ST.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW ORLEANS
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70119
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
504-821-2545
Provider Business Mailing Address Fax Number:
504-304-1446

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1204 N BROAD ST.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW ORLEANS
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70119
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
504-821-2545
Provider Business Practice Location Address Fax Number:
504-304-1446
Provider Enumeration Date:
03/18/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223G0001X , with the licence number: 5997 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1859974 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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